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Home My WebLink AboutFlaky Crust Pies - 12/31/2021FOR BOARD OF HEALTH USE ONLY Date Received Permit Fee Approved By Permit# Issued $25 Farmer's Market Permit Application (Application must be submitted at least 7 business days before the planned opening date) 1) Establishment Name: �-7t rA� C" t e 2) Establishment Mailing Address: " o of a C 07 _ (,� 3) Establishment Telephone No; 4) Applicant/Owner Name &Title: 'v1 5) Applicant/OwnerAddress., I u ' �, 62-7 U 6) Applicant/Owner Telephone No: 7) ApplicantlOwner Email address: 8) Person Directly Responsible For Onaite Operations: _ r Name $ Title: JI- A -x-� Address: i ar c) �P-7o Telephone No: -7 CCFax: Emergency Telephone No: q01_ - 9) Check one If preparing food: Retail food 10). Water Source: ❑ Food Truck ❑ Caterer 11) Sewage disposal plan: ❑ Other: 12) Please give a brief description of the food to be sold or served: 5�nalt, Ia(6j , b(-11 e. si rub �LL nn� cook-t -es 13) If samples are being served, please describe sampling protocols: / Pl"(5 5 (f CeC( C vl �(% ac f /1 ,5/ 14) Food will be prepared: ❑ Onsite for immediate consumption 15) Solid waste disposal plan: 1 W1 t i 0 & V-1Z-- � ❑ Onsite and held at proper hot/ cold holding temperatures X Offsite and held at hot/ cold holding temperatures Lk)t f fir,., ,�.��/[ r✓A�p� bGt-tri proper ❑ Offsite, cooled and reheated on site C��1 \ _ .. S. Ck 0\-,r 1LKK� ❑ Other: If PHF is being complete food 6 I 11 �it prepared, please protection questionnaire 16) If PHF is being served, please list the person who has completed the following trainings and attach appropriate certificates: ❑ Food Safety Manager. --- ❑ Allergen Awareness: 17) For caterers, Cityfrown where food establishment permit is held. Please attach a copy of the caterer's permit: For food trucks, please list additional communities where a food permit is held and attach copies of the permits: 1, the undersigned, attest to the accuracy of the information provided in this application and 1 affirm that the food establishment operation will comply with 105 CMR 590.000 and all oth applicable law. I have been instructed by the board of health on how to obtai�copie�s,,of 105 CMR �90.000 aWe federal Food Code. 18) Signature of Applicant: Pursuant to MGL Ch. 62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid state taxes required under law. 19) Social Security Number or Federal ID: �(�, o i n3 20) Signature of Individual or Corporate Name: _ 1 a K- ,�j 1y- J5- F I tj ( Z—� Food Protection Questionnaire for Farmer's Market Dates at Market: J Vb!j _ -.2e- eT T Location of Event: _Farmers Market 888 South Main Street Mansfield MA List all foods that you will be chilling, holding, cooking, and/or re heating at the event location: On is of igerated Coking Rehea ' g pr is Food Manager Certification Person Trained On Site? Yes ❑ No Allergen Awareness Menu Label Present? 'Wyes ❑ No List 1 Potentially Hazardous Food (PHF) and the individual intended temperature required: List the required temperature for each food as it leaves your preparation site: How will the PHF be kept at or below 41°F? How will the PHF be kept at or above 140°F? Time of PHF? Setup Served Removed List all equipment that will be supplied for the Market, including but not limited to food thermometers, cleaning wipes, utensils, non latex gloves, heating utensils, ice etc. � i� T/te Commonwealth of Massachusetts Department of Industrid Accidents Office of Investigations 600 Washington Street Boston, MA 02111 IV wwty. mass gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Are y u an employer? Check the appropriate box: 1.FI am a employer with ` employees (full and/ or part-time).* 2. ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3. ❑ We are a corporation and its officers have exercised their right of exemption per c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required]° C ❑ We are anon -profit organization, staffed by volunteers, with no emplovees. INo workers' comp. insurance rea.] Business Type (required): 5. ❑ Retail 6. 5pestamant/Bar/Eating Establisbment 7. ❑ Officepnd/or Sales (incl. real estate, auto, etc.) 8, ❑ Non-profit 9. ❑ Eutertainmern 10.❑ Manufacturing I LE] Health Care 12.❑ Other___ _... _ *Any appliezntt at checks box #t must also fill out the section below showing their work=' compensationpolicy information. "If the corpomlo officers have exempted themsolves, butthe corporation has other employees, a workers' compensation policy is required and such an organization should check box #l. I also an employer that is propifling lvo fAers' compensation lusurance for my employees. Below is the policy information. Insurance Company Insurer's Address; City/State/Zip: Policy # or Sell Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Imestieations of the DIA for insurance covemee verification. hereby - --tom c. — ofperjury that the Offwial use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # is true and correct. Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6.Other 1Vumvuu6a4oa0M TAX CERTIFICATION FORM I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. (akz,, �- aial, A, Signature of Individual or Corporate Name By: Corporate Offi r (Mandatory, if Applicable **Social Security No. (Voluntary) or Federal Identification Number *This license will not be issued unless this certification clause is signed by the applicant. ** Your social security number will be furnished to the Massachusetts Department of Revenue to determine whether you have met tax filing or tax payment obligations. Licensees who fail to correct their non -filing or delinquency will be subject to license suspension or revocation. This request is made under the authority of Massachusetts General Law Chapter 62C, section 49A. May 13, 2021 Account Policy Information: Agency Name ROBERT W EAMES INSURANCE AGNCY INC Agency Code 08089667 Recipient Information Flaky Crust Pies, LLC 164 RICHARDSON AVE ATTLEBORO MA 02703-1220 SUMMARY OF INSURANCE Account PolicyReca Policy Number Policy Term Premium Workers Compensation 11/2612020 to Hartford Fire 08 WEC AC4F7F $3,365 Insurance 11/26/2021 Company 5113/2021 Application Fom Norton Health Department 70 East Main St. Norton, MA 02766 (508) 285-0200 COMMONWEALTH OF MASSACHUSETTS TOWN OF NORTON BOARD OF HEALTH Flaky Crust Pies 401 OLD COLONYRD Number FE-21-0047 Fee $ $50.00 DATE ISSUED 02108121 IS HEREBY GRANTED A BAKERY This permit is granted in conformitywith the Statutes and ordinances relating thereto, and expires orrevoked. Comment: Christian Zahner IV Health Agent 12131121 unless sooner suspended